Journalof Speech and HearingDisorders, Volume 55, 439-453, August 1990
CHARACTERIZATION OF TINNITUS BY TINNITUS PATIENTS J. L. STOUFFER Departmentof Otolaryngology-Headand Neck Surgery University of Iowa Hospitals and Clinics, Iowa City Department of Communicative Disorders University of Western Ontario, London, Ontario,Canada RICHARD S. TYLER Departmentof Otolaryngology-Head and Neck Surgery University of Iowa Hospitalsand Clinics, Iowa City Department of Speech Pathology and Audiology University of Iowa, Iowa City A questionnaire was administered to 528 tinnitus patients to obtain data on their reactions to tinnitus. Results include a discussion of: (a) population characteristics, (b) perceptual characteristics, (c) the impact of tinnitus on daily life, and (d) etiology. Significant gender differences are also discussed. Tinnitus was not an occasional phenomenon, but was present for more than 26 days per month in 74% of the patients. Other important findings about tinnitus include: (a) Hearing levels at 1000 and 4000 Hz were -25 dB HL for 18% of the tinnitus patients, which suggests that some patients had normal hearing or mild hearing losses; (b) the prevalence of tinnitus in patients with noise-induced hearing loss (NIHL) was 30% for males and only 3% for females; (c) about 25% of the patients reported tinnitus severity had increased since tinnitus onset; (d) the effects of tinnitus were more severe in patients who reported tinnitus as their primary complaint and in patients diagnosed as having M6niere's syndrome tinnitus; and (e) some patients reported that noise exacerbated their tinnitus, whereas others reported that a quiet background exacerbated their tinnitus. KEY WORDS: tinnitus, noise-induced hearing loss, rating scales and tinnitus
Tinnitus is a common and often debilitating condition. In the USA, a general population survey indicated that 32% of the population had some form of tinnitus and that it was severe in 2% (National Center for Health Statistics, 1967, 1980). In a general survey in the United Kingdom, 35% of the adult population studied reported tinnitus of some type. It was severe in 1% and 0.5% noted it had a severe effect on their ability to lead a normal life (Coles, 1984a). During the last decade interest in tinnitus research has dramatically increased. A variety of studies have quantified tinnitus psychophysically (e.g., Bums, 1984; Penner, 1983, 1986a; 1986b; Tyler & Conrad-Armes, 1983). A few studies have provided information on the prevalence and social and psychological consequences of tinnitus. Tyler and Baker (1983) administered an open-ended questionnaire to 72 members of the Nottingham tinnitus self-help group. Problems listed by at least 15% of the respondents were (a) getting to sleep, (b) persistence of tinnitus, (c) understanding speech, (d) depression, (e) annoyance, (f) confusion, and (g) dependence on drugs. Although a slight negative correlation was found between number of problems and tinnitus duration, the results were too limited to conclude that people learn to live with tinnitus. About 23,000 questionnaires were mailed to a random sample from the British adult population and 19,000 were returned (Coles, 1984a, 1984b). Those respondents who had tinnitus reported annoyance, sleep disturbance, and a 0 1990, American Speech-Language-Hearing Association
severe effect on their ability to lead a normal life. Coles (1984b) concluded that the prevalence of tinnitus increases with age and with noise exposure. Slater and Terry (1987) reported on a survey of about 1,000 tinnitus patients in Wales. About 40% of the patients were members of the British Tinnitus Association, and the remaining participants were obtained from a newspaper advertisement. Slater and Terry (1987) stated that tinnitus interfered with sleep and that relief from tinnitus was obtained when patients were active, absorbed, involved, or interested in some activity. Fortytwo percent of the respondents were taking medications to sleep. Lindberg, Lyttkens, Melin, and Scott (1984) reported on 1,047 patients from a Swedish hospital hearing center associated with departments of audiology and otolaryngology. Fifty-nine percent of the patients were troubled by tinnitus. Twenty-one percent reported no subjective hearing loss, and 9% of hearing aid users were more troubled by tinnitus than by their hearing loss. Lindberg et al. (1984) suggested that the extent of the problem associated with tinnitus is obscured because patients are informed there is no treatment available. Thus, the patient does not pursue treatment for tinnitus although s/he often subjectively regards tinnitus as a greater handicap than a concomitant hearing loss. Jakes, Hallam, Chambers, and Hinchcliffe (1985) analyzed tinnitus complaints collected from 82 neuro-otology patients. Patients objected to the persistence of their 439
440 Journal of Speech and Hearing Disorders tinnitus and reported sleep disturbance, emotional distress, and interference with passive auditory leisure time activities. Patients' awareness of tinnitus correlated significantly with self-reported tinnitus loudness and the unpleasantness of their tinnitus. Jakes et al. (1985) concluded that work and family life were dramatically affected by tinnitus and that helping patients understand their tinnitus symptoms might reduce feelings of helplessness. The American Tinnitus Association (1986) mailed a questionnaire to about 130,000 of their members; about 13,000 were returned, and 2,550 were analyzed. Thirtyeight percent characterized their tinnitus as ringing, and 77% reported tinnitus was always present. Twenty-four percent reported a moderate amount of interference with their general enjoyment of life. Furthermore, 6% had permanently or temporarily quit work as a result of tinnitus. Thirty-six hundred questionnaires were mailed to a random sample of Gothenburg, Sweden, residents, and 2,378 usable questionnaires were returned (Axelsson & Ringdahl, 1989). Six percent of the population reported that tinnitus was always present, that it was more common in the left ear, and that it was often related to hearing loss. Of those who always had tinnitus, however, 19% reported subjectively normal hearing. Tinnitus sufferers also reported difficulty in falling asleep and were sometimes awakened by tinnitus. Axelsson and Ringdahl (1989) concluded that more resources are needed to describe further the factors relating to tinnitus and in particular to develop treatment. The present paper focuses on a clinical population that is representative of patients seen for treatment. In addition to extending previous work and examining several areas in depth, we characterize our patients in detail. In particular, we measure hearing thresholds, document the intermittent nature of tinnitus, and document otolaryngological and/or audiological diagnosis. METHOD A questionnaire was distributed to the audiology-otology departments of four hospitals. Notices requesting tinnitus patients to fill in the questionnaires were placed in each facility. The population sample obtained does not constitute a random sample from the general population but is representative of a clinical population. The entire questionnaire is found in the Appendix. Questions in Part A deal with the patient's description of tinnitus, problems associated with tinnitus, and other aspects of tinnitus from the patient's perspective. Part A was completed by the patient before s/he was evaluated audiologically or medically. The patients completed Part A without assistance, but they were encouraged to ask questions. Part B of the questionnaire consists of three questions: one about primary diagnosis, a second about the patient's primary complaint, and a third identifying air-conduction thresholds at 1000 and 4000 Hz bilaterally. This section was completed by an audiologist during the audiological
evaluation. The questions are referred to throughout the text as A1-A30 and B1-B3. Audiologists recorded the primary complaint, obtained air-conduction hearing levels at 1000 and 4000 Hz bilaterally, and indicated the primary diagnosis. Patients were encouraged to ask for clarification. When possible, questionnaires were checked for completeness by an audiologist before the patient left the clinic. In the present study, many responses were compared by using the chi-square statistic. Chi-square contingency table values were considered significantly different if the residual was equal to or greater than two standard deviations from the expected value. RESULTS
Results and discussion are organized into four areas of interest: (a) population characteristics, (b) perceptual characteristics, (c) the impact of tinnitus on daily life, and (d) etiology. Only statistically significant gender differences are mentioned, although they were evaluated for all questions. Population Characteristics The sample was composed of 293 males and 235 females. The mean age was 49 (SD = 16.1) with a range of 14-88 years; 52% of the sample was at or above 50 years of age. Air-conduction hearing levels, measured for 1000 and 4000 Hz, were 25 dB HL for 18% of the patients. Subjective results of normal hearing for tinnitus patients have been reported by other studies: 22% (Slater, Jones, & Terry, 1983), 21% (Lindberg et al., 1984), and about 20% (Axelsson & Ringdahl, 1989). However, none of these studies reported threshold measures, and we had threshold measures only at two frequencies. It is likely that many patients had high-frequency hearing losses (McFadden, 1982). We suspect that the percentage of tinnitus patients with normal hearing has been overestimated. In the present study, males had average hearing levels about 25 dB poorer at 4000 Hz compared to 1000 Hz; females had hearing levels about 10 dB poorer. Threshold differences were not significant for males and females at 1000 Hz; however, they were significantly different at 4000 Hz. The average 4000 Hz HL in the right ear for males was 47 dB (SD = 26.3) and for females 38 dB (SD = 28.5), t(526) = 3.94, p < .0001. The average in the left ear for males was 50 dB (SD = 26.8) and for females 38 dB (SD = 26.3), t(526) = 5.26, p < .0001. The significant difference in hearing levels for males and females at 4000 Hz cannot be completely explained by differences in identifiable noise exposure. If the patients with tinnitus attributed to noise-induced hearing loss (NIHL) are excluded, 4000 Hz thresholds remain better in females than in males by 9 dB in the left ear and 8 dB in the right ear.
STOUFFER & TYLER: Characterizationof Tinnitus
Table 1 shows that 44% of the males and 49% of the females did not know the cause of their tinnitus (Question A21). The categories most frequently chosen by the remaining respondents included accident, hearing loss, illness, and noise. The chi-square for perceived cause of tinnitus for males and females was significant [X2(6, N = 528) = 44.26, p < .001], with more males than females believing that their tinnitus was caused by noise. Table 2 lists the patients' primary complaints. Fortyeight percent complained primarily of tinnitus, and 38% complained primarily of hearing loss (Question B2). Table 3 lists the results of one-way analyses of variance between patients complaining primarily of tinnitus or hearing loss for the variables: (a) pitch, (b) loudness, (c) percentage of time present, (d) days per month bothered by tinnitus, (e) years present, (f) years bothered by tinnitus, (g) annoyance, (h) sleep interference, (i) depression, (j) concentration, and (k) interference with speech. Table 3 shows that patients whose primary complaint was hearing loss reported that their tinnitus interfered more with speech, and also that it was present and "bothered" them for more years. For the group whose primary complaint was tinnitus it was present for more time each day, for more days per month, it interfered more with their sleep, and it resulted in more depression. However, the group whose primary complaint was tinnitus had experienced tinnitus for fewer years than the group whose primary complaint was hearing loss. It is not surprising that patients whose primary complaint was tinnitus reported more tinnitus-related problems as compared to persons whose primary complaint was hearing loss even though in the former group tinnitus onset was more recent. Perhaps patients who have had tinnitus longer adjust to it and the focus of their problem becomes communication difficulties. However, this is not necessarily true. Patients whose primary complaint is tinnitus may have a more distressing tinnitus and seek help shortly following tinnitus onset. Patients frequently report that tinnitus interferes with speech (e.g., Axelsson & Ringdahl, 1989; Hazell et al., 1985). However, it is not possible to differentiate whether it is the tinnitus that interferes with speech or whether it is TABLE 1. Responses to Question A21, "What do you think originally caused your tinnitus?" Question A21: Cause
% of males
% of total
Noise Hearing loss Illness Accident Drugs/medicine Surgery Food Alcohol Smoking Other No idea
22.5 10.9 9.2 7.8 2.4 0.6 0 0 0 2.4 44.0
3.8 15.3 15.3 6.8 2.6 3.8 0.4 0 0 3.4 48.5
14.2 12.9 11.9 7.4 2.5 2.1 0.2 0 0 2.8 46.0
TABLE 2. Patients' primary complaint.
Question B2: Complaint
% of total
Tinnitus Hearing loss Dizziness Other Pain/headache
47.7 37.7 11.0 2.7 0.9
the hearing loss. In the present study, patients whose primary complaint was hearing loss reported more difficulty understanding speech. They had a less severe tinnitus and hearing thresholds that were 20 dB poorer than the tinnitus group. Consequently, it seems likely that patients confuse the effects of tinnitus on speech understanding with the effect of hearing loss on speech understanding. Table 4 describes the perceived locus of tinnitus (Question Al). The most frequent response (top panel) was "left ear" followed by "both ears equally," "both ears-worse in left," and then "right ear." The middle panel shows that more patients heard tinnitus on the left side. The bottom panel shows that more patients had bilateral tinnitus than unilateral tinnitus. About 10% heard tinnitus in the head, whereas less than 1% perceived it as coming from outside the head. The present data agree with previous studies in indicating a higher prevalence of left-ear tinnitus (e.g., American Tinnitus Assocation, 1986; Axelsson & Ringdahl, 1989; Coles, 1984b; Slater et al., 1983). Several hypotheses have been proposed to account for the prevalence of left-sided tinnitus including handedness and asymmetric noise exposure. Coles, Davis, and Haggard (1987) controlled for the age dependency of handedness reported by Fleminger, Dalton, and Standage (1977) and concluded that tinnitus laterality was not significantly related to handedness. Coles et al. (1987) also reported that the correlation between the side of predominant noise exposure and the side of tinnitus was not significant. Perhaps the occurrence of predominantly left-sided tinnitus is related to the physiological asymmetry of the lower brainstem in humans (Decker and Howe, 1981, 1982; Lobaugh, Parker, Thornton, & Berlin, 1980). Table 5 lists the terms patients used to describe tinnitus (Question A8). The most common descriptors were "ringing," "buzzing," "cricket," and "hissing." A significant gender difference was found for the pattern of responses across all description categories, X2(11, N = 528) = 30.9, p < .001. However, an examination of the chi-square contingency table revealed that none of the individual description categories was equal to or greater than two standard deviations from the expected value. Figure 1 indicates the percentage of time during a day that patients were aware of tinnitus (Question A10). Sixty-eight percent of the patients heard tinnitus for more than 80% of the day. The average rating for time present was 80% (SD = 31.8). Although the difference in time of
442 Journal of Speech and Hearing Disorders
TABLE 3. Differences between patients whose primary complaint was hearing loss and patients whose primary complaint was tinnitus. Complaint a. % of time tinnitus is present. F(1, 449) = 10.63, p < .001
Hearing loss Tinnitus b. Days per month patients are "bothered" by tinnitus. F(1, 449) = 10.83, p < .001 Hearing loss Tinnitus c. Years tinnitus was present. F(1, 449) = 30.62, p < .001 Hearing loss Tinnitus d. Years patients were "bothered" by tinnitus. F(1, 449) = 11.25, p < .001 Hearing loss Tinnitus e. Interference with sleep from tinnitus. F(1, 449) = 14.32, p < .001 Hearing loss Tinnitus f. Degree patients are depressed by tinnitus. F(1, 449) = 12.28, p < .001 Hearing loss Tinnitus g. Degree to which tinnitus interferes with speech. Hearing loss F(1, 449) = 9.72, p < .001 Tinnitus
Note. Means and standard deviations for e, f, and g represent ratings on a 0-100-point scale.
enced tinnitus for as long as 65 years. For the total sample, the average time since tinnitus onset was 7.6 years (SD = 9.9). These findings indicate that most patients in the study had experienced tinnitus recently and that it was present for most of the time. Seventy-four percent of the patients used medications immediately prior to tinnitus onset, but only 45% used
awareness between males (M = 83%; SD = 29.6; n = 293) and females (M = 76%; SD = 33.9; n = 235) was statistically significant [t(526) = -2.58, p < .01], it was
very small. Sixty-two percent of the patients reported that their tinnitus onset occurred within the last 5 years, whereas 18% reported onset within the last 6-10 years (Question A17). However, 1% of the patients had experi-
TABLE 4. Patients' responses to Question Al, "Where is your tinnitus?" Perceptual locus a. b. c. d. e. f. g. h. i. j.
Left ear Both ears equally Both ears-worse in left Right ear Both ears-worse in right In head-more right side In head-more left place In head-no exact place In middle of head Outside of the head Total
Left (a, c, g) Right (d, e, f) Total Unilateral (a, d) Bilateral (b, c, e) Head (f, g, h, i) Outside (j) Total
20.1 22.2 18.4 14.0 16.7 3.1 2.4 1.4 1.4 0.3 100.0
23.0 17.9 13.6 18.3 14.5 3.0 3.8 3.8 1.3 0.9 100.1
21.4 20.3 16.3 15.9 15.7 3.0 3.0 2.5 1.3 0.6 100.0
40.9 33.8 74.7
40.4 35.8 76.2
40.7 34.6 75.3
34.1 57.3 8.3 0.3 100.0
41.3 46.0 11.9 0.9 100.1
37.3 52.3 9.8 0.6 100.0
Note. The middle panel groups responses to left or right (side or ear). These data were obtained by combining the categories from the top panel that correspond to the letters in the parentheses to the right of "left" and "right." The bottom panel groups the responses as unilateral (right or left ear), bilateral, in the head, and outside of the head. These data were obtained in the same manner as the data in the middle panel.
STOUFFER & TYLER: Characterizationof Tinnitus TABLE 5. Patients' responses to Question A8, "Which of all these
qualities best describes your tinnitus?" Question A8: Descriptor
% of males
% of total
Ringing Buzzing Cricket Hissing Whistling Humming Roaring Musical note Steam whistle Pulsing Rushing Crackling Throbbing Whooshing Clicking Pounding Clanging Popping
41.3 7.8 7.5 9.2 9.2 4.1 4.4 5.1 4.4 2.0 2.0 0.3 0.7 0.3 0.3 0.7 0.0 0.3
32.8 15.3 9.8 6.0 3.4 6.8 4.7 3.0 3.4 6.0 3.0 2.6 0.9 0.9 0.9 0.0 0.9 0.0
37.5 11.2 8.5 7.8 6.6 5.3 4.5 4.2 4.0 3.8 2.5 1.3 0.8 0.6 0.6 0.4 0.4 0.2
medications at the time they completed the questionnaire (Questions A29 and A30). This difference was significant, X2 (1, N = 528) = 48.8, p < .01. Females used medications
more often than males, both prior to tinnitus onset [X2 (1, N = 528) = 60.1, p < .01] and at present [X2 (1, N = 528) = 106.8, p < .01].
It cannot be determined if medications precipitated or exacerbated tinnitus and thereby resulted in decreased use of medications. Alternatively, drug use could have been related to changes in general health. We do know that some medications trigger tinnitus (e.g., Brown et al., 1981; McFadden, 1982). In addition, Tyler and Baker (1983) noted that some patients complain about their reliance on medications to treat tinnitus. Some of the more common drugs that precipitate tinnitus are salicylates, quinine, alcohol, and oral contraceptives. All tinnitus patients should be informed of the effects of these and other drugs that are known to induce or exacerbate tinnitus. Perceptual Characteristics Patients were asked to rate the relative pitch of their tinnitus on a scale from 1 to 10 (Question A2); the lower the number, the lower the pitch. Figure 2 shows that 65% rated their tinnitus pitch at 7 or higher, and only 13% of the patients rated pitch as 4 or less. The average pitch rating was 7.1 (SD = 2.3). The observation that most patients report a high-pitched tinnitus agrees with Slater et al. (1983). High-pitched tinnitus may be associated with highfrequency hearing loss (e.g., Clark, 1984). In the present study, however, the difference in average pitch rating for patients with hearing levels >50 dB HL at 4000 Hz was
not significantly different from patients with hearing
levels -25 dB HL, t(276) = .85, p = .39. An average pitch rating of 7.3 (SD = 2.4) was recorded for the 167 patients with bilateral 4000-Hz thresholds >50 dB HL, and an average pitch rating of 7.1 (SD = 2.3) was recorded for the 111 patients with bilateral 4000-Hz thresholds -25 dB HL at 4000 Hz. It should be noted that little relationship was found between scaled pitch and pitch-matching measurements by Tyler and Conrad-Armes (1983). For example, 1 subject with a scaled pitch rating of 6 on a 1-6-point scale matched his tinnitus to 37 Hz. Because individual opinions differ about what constitutes a high or low pitch, comparisons of scaled values between subjects are difficult to make. However, within-subject scaling procedures have been shown to be reliable and valid (e.g., Hellman & Meiselman, 1988; Stevens, 1959). Patients were asked to rate the relative loudness of their tinnitus on a scale from 1 to 10 (Question A5); the lower the number, the softer the tinnitus. Figure 3 shows that more patients rated their tinnitus as relatively loud than rated their tinnitus as relatively soft (34% reporting 8 or higher versus 12% reporting 3 or lower). The average loudness rating of 6.3 (SD = 2.3) is in good agreement with the average loudness rating of 5.4 on a 0-10-point scale reported by the American Tinnitus Association (1986). The difference between the average loudness for males (M = 6.1, SD = 2.3) and females (M = 6.5, SD = 2.3) was small but statistically significant, t(526) = -2.01, p = .045. We speculated that the loudness difference for gender resulted mainly from the NIHL patients. NIHL patients rated tinnitus loudness as less than patients in other major diagnostic categories (presbycusis, M6niere's, and middle-ear), and of 95 NIHL patients, 88 were male. When NIHL patients were excluded from the analysis, gender differences for tinnitus loudness were no longer significant, t(431) = -.93, p = .35. Patients were asked to indicate the number of days per month they were bothered by tinnitus (Question All). Seventy-four percent were bothered from 26 to 30 days per month. The remaining 26% of the responses were distributed relatively evenly between 1 and 25 days per month. Thus, tinnitus was present nearly every day for three fourths of the sample. When tinnitus was present, its pitch did not change for 52% of the patients (Question A3). When tinnitus pitch did change, it changed suddenly (28%) or gradually (21%). We also asked if tinnitus pitch varied from day to day to determine if some patients experienced a regular fluctuation in their tinnitus (Question A4). Sixty-four percent responded that tinnitus pitch did not vary daily. However, 36% did experience daily fluctuations. Finally, we asked if pitch had changed since tinnitus onset (Question A12). For 19% of the patients, pitch was higher, 5% reported that it had lowered, and 76% reported that it was the same. Almost three fourths of the patients (73%) indicated that their tinnitus never changed to a completely different sound (Question A9). The remaining 27% indicated that
444 Journal of Speech and Hearing Disorders
21-40 41-60 61-80 81-100 1-20 PERCENT OF TIME TINNITUS WAS PRESENT FIGURE 1. Percentage of time per day tinnitus was present in 20% intervals (Question A10). their tinnitus changed either suddenly (16%) or gradually (11%) to a different sound. Most patients indicated that their tinnitus was composed of the same number of sounds now (M = 1.9, SD = 4.5) as it was at onset. For example, of the 372 patients who indicated that their tinnitus was composed of one sound at onset, 310 stated that their tinnitus was composed of one sound now and the remaining 62 said that their tinnitus was composed of two sounds now. Although the number of sounds comprising tinnitus at onset (M = 1.7, SD = 4.1) was only slightly less than the number of sounds comprising tinnitus now, the difference was statistically significant, t(527) = -3.62, p < .0001. Thus, for about one half of the patients, tinnitus had a steady pitch; in the other half, it fluctuated. For about one third of the patients there were overall pitch changes day to day. Finally, for about three fourths of the patients, tinnitus pitch now was about equal to tinnitus pitch at onset. When tinnitus was present its loudness did not change for 44% of the patients (Question A6). When loudness did change, the change was sudden (25%) or gradual (31%). We also asked if tinnitus loudness varied from day to day to determine if some patients experienced regular fluctuations in tinnitus loudness (Question A7); 50% indicated that tinnitus loudness varied daily, and 50% indicated tinnitus loudness did not vary daily. Finally, we asked if loudness had changed since tinnitus onset (Question A13). For 34% of the patients, loudness had increased, 7%
reported that it had decreased, and 60% reported it was the same (Question A13). Thus, for about two fifths of the patients, tinnitus loudness remained steady; in the remaining three fifths, it fluctuated. For one half of the patients there were loudness changes day to day. Finally, for about three fifths of the patients, tinnitus loudness now was about equal to tinnitus loudness at onset. Penner (1983) has indicated that because tinnitus pitch and loudness vary they are difficult to measure reliably. The present study suggests that this may be a problem for some patients, but for others tinnitus pitch and loudness apparently do not vary. In these latter patients perhaps tinnitus pitch and loudness can be quantified more reliably. Research should investigate the variability of psychoacoustical measures of tinnitus pitch, loudness, and masking measures with patients who report stable and with those who report unstable tinnitus. The Impact of Tinnitus on Daily Life About 66% of the patients indicated that tinnitus severity had not changed since onset (Question A14), and 5% reported that it had decreased. However, 28% indicated that it had increased. Patients often ask whether their tinnitus will improve or get worse. Based on the present results, it appears that in about two thirds of the patients tinnitus severity does
STOUFFER & TYLER: Characterizationof Tinnitus
23 18 12
3 4 5 6 7 8 SUBJECIVE PITCH RATING
FIGURE 2. Distribution of responses when asked to indicate pitch on a 10-point scale (Question A2). not change. When a change occurs, however, severity usually increases. Coles, Smith, and Davis (1989), however, reported that if annoyance did change, it decreased in more cases than it increased. This was not the case for tinnitus loudness, where change usually resulted in an increase. Coles et al. (1989) interpreted this result as an example of patients habituating to their tinnitus. Seventy-eight percent of the patients indicated that they were bothered by tinnitus for 5 years or less (Question A18). Of this group, 40% were bothered for 1 year. One percent indicated that they were bothered by tinnitus for as long as 60 years, and 7% did not consider tinnitus bothersome. The average time patients were bothered by tinnitus was 4.9 years (SD = 8.0). Table 6 lists those situations in which tinnitus became worse (Questions A19). Thirty-six percent of the sample listed "being in a quiet place" as making tinnitus worse, and 31% listed "being in a noisy place" as making tinnitus worse. Several other responses relating to noise, including "shooting guns, rifles, etc." and "having just recently been in a noisy place," were also chosen. Twenty percent of the patients indicated that nothing made their tinnitus worse. Two factors made tinnitus worse for females more often than for males: "When I first wake up in the morning," [X2(1, N = 528) = 12.2, p < .01] and "changing head position," [X2(1, N = 528) = 13.0, p < .01]. These differences are large and possibly important, but the reason for them is unclear.
Table 7 lists those situations in which tinnitus severity decreased (Question A20). For 41% of the sample, nothing decreased tinnitus severity. "Being in a noisy place" and "being in a quiet place," which were also selected as making tinnitus worse, made tinnitus better for 19% and 10% of the patients, respectively. "TV/radio," which may be related to being in a noisy place, was also selected by 23% of the population. "Sleep" decreased tinnitus severity for 26% of the sample. One useful treatment approach would be to have patients keep a record of the instances in which their tinnitus severity increases or decreases. They can then determine if patterns exist and try to avoid situations where tinnitus severity increases and maximize the amount of time spent in situations where tinnitus severity decreases. It is noteworthy that the effects of noise dichotomized tinnitus patients into two groups. In some patients, the presence of noise made tinnitus worse. In others, noise decreased tinnitus. This dichotomy may be useful in establishing different tinnitus subpopulations for evaluating the success of maskers, drugs, and other therapeutic trials. Table 8 lists the effects of tinnitus on five different attributes. Patients were asked to respond from 0 to 100, according to the severity of the particular problem. If we arbitrarily consider ratings from 71 to 100 to indicate a substantial problem, annoyance was substantial for 42%,
446 Journal of Speech and Hearing Disorders
hHnHH - H I
5 6 7 8 9 3 4 SUBJECTIVE LOUDNESS RATING
3. Responses indicating loudness of tinnitus on a scale of 1-10. The lower the number, the less loud the tinnitus and vice versa (Question A5). FIGURE
interference with sleep for 17%, depression for 28%, and interference with concentration for 17% of the patients. Tinnitus was rated as more annoying by females (M = 61.4, SD = 31.8) than by males (M = 56.1, SD = 31.1), t(526) = 1.96, p < .05. Females also reported more
interference with sleep (M = 31.7, SD = 35.7) than males reported (M = 24.2, SD = 32.6), t(526) = 2.54, p < .01.
To evaluate the effects of tinnitus on patients, we used a 0-100-point scale. Other studies, however, generally used 3- or 4-point scales (e.g., never, often, always, or
TABLE 6. Responses selected by at least 5% of the patients to Question A19, "When you have tinnitus, which of the following makes it worse?" Situations when tinnitus severity is increased
% of males
% of total
Being in a quiet place Being in a noisy place Emotional/mental stress Having just recently been in a noisy place Lack of sleep Nothing makes it worse When you are tired from physical work Changing head position Shooting guns, rifles, etc. When you are excited When you first wake up in the morning Sudden physical activity Relaxation Alcohol Drugs/medication
37 30 25 30
36 33 34 26
36 31 29 28
18 23 15 11 18 11 8
26 17 22 23 11 14 18
23 20 17 16* 13 12 12*
9 10 7 6
13 11 6 8
10 10 7 7
Note. Patients were encouraged to select as many categories as applied. *Chi-square for sex difference, p < .01.
STOUFFER & TYLER: Characterizationof Tinnitus
7. Responses chosen by a minimum of 5% of the patients to Question A20, "Which of the following reduces your tinnitus?" TABLE
Situations when tinnitus severity is decreased
Nothing Sleep TV/radio Being in a noisy place Being in a quiet place Having just recently been in a quiet place
% of patients selecting variable
41 26 23 19 10 5
Note. Patients were encouraged to select as many categories as applied. never, sometimes, often, always). Because evaluative scales differ from study to study, direct comparisons of results with other studies are not possible. However, the finding that a substantial number of patients complained of annoyance, depression, and interference with sleep and concentration as a result of tinnitus is common (e.g., American Tinnitus Association, 1986; Axelsson & Ringdahl, 1989; Hazell et al., 1985; Slater & Terry, 1987). The finding that females report more interference with sleep and a more annoying tinnitus than males also agrees with previous studies (e.g., Axelsson & Ringdahl, 1989; Coles, 1984b). Whether tinnitus causes annoyance, interference with sleep, depression, and interference with concentration or whether some patients have a predisposition to these symptoms is a moot question. The best method of relieving these symptoms would be to eliminate the cause of the symptoms. Because it is not possible to eliminate tinnitus at present, we need to learn how to help patients cope with the consequences of tinnitus. Sixty percent indicated concern that their tinnitus was a symptom of a much worse disease (Question A27). In addition, 55% indicated that they were concerned about going deaf because of tinnitus (Question A28). This indicates the distress created by tinnitus and points to the need for a widespread, effective public awareness program on tinnitus. Concern about tinnitus would probably be reduced if patients were more knowledgeable about this disorder.
loss, patients should be counseled regarding the use of ear protection devices around the home and at work. We compared responses to several questions for patients with NIHL, presbycusis, M6niere's syndrome, and middle-ear tinnitus. Although the physiological pathologies for presbycusis and M6niere's syndrome are not well understood, all four classifications are commonly used and warrant further investigation. For the present sample, the average age of patients was 64 years (SD = 9) for presbycusis, 51 years (SD = 13) for NIHL, 50 years (SD = 16) for M6niere's syndrome, and 41 years (SD - 17) for middle-ear disease. Thus, patients whose tinnitus was associated with presbycusis were older and, as the standard deviation indicates, their age range was more restricted than the age range for other groups. Table 10 compares these etiological categories for (a) pitch, (b) loudness, (c) annoyance, (d) depression, and interference with (e) sleep, (f) concentration, and (g) speech. In comparisons between NIHL and M6niere's syndrome tinnitus (columns 1 and 3), subjective loudness, annoyance, depression, and interference with sleep and speech were significantly greater for M6niere's syndrome tinnitus patients. In comparisons between presbycusis and M6niere's syndrome tinnitus patients (columns 2 and 3), annoyance, depression, and interference with concentration and speech were significantly higher for the M6niere's syndrome tinnitus patients. Finally, in comparisons between the Meniere's syndrome and middle-ear tinnitus patients (columns 3 and 4), loudness was significantly higher for M6niere's syndrome tinnitus patients. M6niere's syndrome patients typically indicated greater severity of symptoms (tinnitus was louder, more annoying, and more depressing and interfered more with sleep, concentration, and speech) than did patients with tinnitus resulting from NIHL, presbycusis, or middle-ear disease. Meniere's syndrome patients must also attempt to cope with the other debilitating effects associated with M6niere's syndrome (intermittent, unpredictable spells of dizziness and hearing loss) in addition to attempting to cope with tinnitus. The frustration encountered by these patients due to the combination of their symptoms may contribute to their more troublesome tinnitus as compared to NIHL, presbycusis, or middle-ear disease tinnitus patients. Thus, although counseling is important for all tinnitus patients, it may be especially important for Meniere's syndrome tinnitus patients.
Etiology Table 9 lists the primary diagnosis (Question BI) based on the otolaryngological or audiological evaluation. The most frequent diagnosis was "unknown" (36%). The second most frequent diagnosis was NIHL, which included 30% of the male but only 3% of the female patients. The difference between the number of males and females with NIHL was significant, X2(6, N = 528) = 69.5, p < .01. For patients exposed to occupational noise there is about a 70% risk of tinnitus (Coles, 1984b). Because noise exposure can cause tinnitus and hearing
Summary 1. Although tinnitus is normally associated with hearing loss, air-conduction hearing levels at 1000 and 4000 Hz were equal to or less than 25 dB HL for 18% of the sample. Thus, some tinnitus patients have relatively normal hearing at least up to 4000 Hz, and the communication handicap resulting from their hearing loss should be minimal. These patients may respond better to tinnitus maskers than to hearing aids.
448 Journal of Speech and Hearing Disorders
55 439-453 August 990
TABLE 8. Patients' ratings on annoyance, interference with sleep, depression, concentration, and interference with speech.
Question A22: How annoying*
Question A23: Interferes with sleep**
Question A24: How depressed
Question A25: Hard to concentrate
Question A26: Interferes with speech
0 1-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 91-100
2.3 9.3 4.5 9.5 5.5 16.7 5.5 4.7 15.5 6.6 19.9
36.9 18.2 6.4 6.3 3.0 10.4 0.8 1.1 4.9 1.3 10.6
35.2 15.3 4.5 9.3 2.5 11.6 1.5 1.5 8.0 2.8 7.8
29.7 15.0 8.1 10.2 2.8 12.9 2.5 1.7 7.0 3.0 7.0
36.4 12.1 4.9 9.3 4.7 13.6 3.4 2.1 4.9 3.2 5.3
Note. Patients rated each variable from 0 (no effect) to 100 (maximum effect). The left column groups the ratings in 10-unit increments except for 0. Remaining column values are the percentage of patients responding. *Mean rating differs by sex, t(526) = 1.96, p = .05. **Mean rating differs by sex, t(526) = 2.54, p = .01.
2. The prevalence of tinnitus associated with NIHL was 30% for males and 3% for females. 3. Sixty-five percent ranked tinnitus pitch as 7 or higher on a subjective scale (1-10). 4. Seventy-six percent reported that, although there were intermittent fluctuations in tinnitus pitch, pitch had not changed since onset. 5. Forty-seven percent ranked tinnitus loudness as 7 or higher on a subjective loudness scale (1-10). 6. Sixty percent reported that, although there were intermittent fluctuations in tinnitus loudness, loudness had not changed since onset. 7. Tinnitus interfered with the daily lives of many patients. Tinnitus was annoying and was associated with
depression and interference with concentration and sleep. 8. Several factors were listed as making tinnitus worse. Some of the more common were: being in a quiet or noisy place, emotional or mental stress, and lack of sleep. TABLE 9. Primary diagnosis made by an otolaryngologist or
audiologist. Question BI: Primary diagnosis Unknown NIHL Presbycusis Mniere's Middle-ear Normal Retrocochlear Perilymph fistula Head trauma Ototoxic Total %
% of males
% of total
29.7 30.0 9.2 10.9 10.6 6.1 1.4 0.7 0.7 0.7
43.4 3.0 15.7 13.2 13.2 9.8 1.3 0.4 0 0
35.8 18.0 12.1 11.9 11.7 7.8 1.3 0.6 0.4 0.4
9. Several factors were listed as making tinnitus better. These included sleeping and listening to radio or watching TV. 10. Slightly more than 25% of the patients reported that tinnitus severity had increased since tinnitus onset. 11. Sixty percent indicated concern that tinnitus was a symptom of a worse disease, and 55% expressed a fear of going deaf. 12. Forty-eight percent considered tinnitus their major problem. These patients were more annoyed by tinnitus, had more difficulty sleeping because of tinnitus, and were more depressed by tinnitus than the 38% who considered hearing loss their major problem. 13. Mniere's syndrome patients reported that their tinnitus was louder, more annoying, and more depressing and interfered more with sleep, concentration, and speech than patients whose tinnitus was associated with NIHL, presbycusis, or middle-ear disease. These descriptive characterizations of tinnitus should help clinicians to understand the patients' perceptions of their problem and provide information useful in designing therapeutic programs and research. The results emphasize the very grave impact of tinnitus. Many patients suffer from lack of sleep, difficulty in concentrating, and fear of other health-related problems. There appear to be several subgroups of tinnitus patients, for example: (a) some who are bothered by noise and (b) some who prefer to be in a noisy background. These subgroups should be explored in more depth in future treatment studies. It is also notable that patients with Mniere's syndrome are generally more distressed than patients with other etiologies. Tinnitus and its effects on different diagnostic categories must also be examined in greater depth to determine if treatment varies across diagnostic categories. Our understanding of tinnitus and its consequences has improved. Systematic and controlled exploration of
STOUFFER & TYLER: Characterizationof Tinnitus
TABLE 10. Means and standard deviations for comparisons among patients whose primary complaint was NIHL, presbycusis, Mdniere's, and middle-ear tinnitus. NIHL n = 95
Presbycusis n = 64
Meniere's n = 63
Middle-ear n = 62
Pitch Loudness Annoyance Depression Interferes with: sleep concentration speech
7.5 5.81,3 54.81,3 22.71,3
2.1 2.3 29.6 29.4
7.2 6.6 48.92'3 20.723
2.4 2.4 32.7 30.2
7.1 7.23,4 69.0 38.7
2.4 2.1 30.9 36.8
7.0 6.0 58.0 25.6
2.4 2.3 29.5 32.4
18.81,3 25.6 23.1 ',3
27.2 28.2 25.6
27.6 20.023 20.72,3
35.7 27.0 29.8
31.4 37.4 42.4
35.2 33.2 33.6
28.8 33.4 30.6
36.6 34.7 30.7
Note. Superscripts indicate significant differences. For example the superscripted 1,3 appearing in column 1 NIHL across from loudness indicates a significant difference in loudness between the NIHL and M6niere's syndrome tinnitus groups. All differences were at the .01 level or less.
different treatment schemes on subgroups of tinnitus patients is now needed.
ACKNOWLEDGMENTS Portions of the data analysis were supported by CLINFO Grant No. RR 59 from the Clinical Research Centers Branch, National Institutes of Health. We wish to thank Dr. Joe Hall, Dr. Paul Kileny, and Dr. Larry Dalzell for their help in collecting the data. Dr. Ross Coles made helpful comments on this manuscript.
REFERENCES AMERICAN TINNITUS ASSOCIATION. (1986). Tinnitus patient survey. Portland, OR: Author. AXELSSON, A., & RINGDAHL, A. (1989). Tinnitus-A study of its
prevalence and characteristics. British Journal of Audiology, 23, 53-62. BROWN, R. D., PENNY, J. E., HENLEY, C. M., HODGES, K. B., KUPETZ, S. A., GLENN, D. W., & JOBE, J. C. (1981). Ototoxic drugs and noise. In D. E. Evered & G. Lawrenson (Eds.), Tinnitus [Ciba Foundation Symposium 85] (pp. 151-171). Bath, England: Pitman Press. BURNS, E. M. (1984). A comparison of variability among measurements of subjective tinnitus and objective stimuli. Audiology, 23, 426-440. CLARK, J. G. (1984). Tinnitus-An overview. In J. G. Clark & P. Yanick, Jr. (Eds.), Tinnitus and its management: A clinical text for audiologists (pp. 3-14). Springfield, IL: Charles C. Thomas. COLES, R. A. (1984a). Epidemiology of tinnitus: (1) Prevalence. In A. Shulman &J. C. Ballantyne (Eds.), Proceedingsof the II International Tinnitus Seminar (pp. 7-15). Ashford, Kent, England: Invicta Press. COLES, R. A. (1984b). Epidemiology of tinnitus: (2) Demographic and clinical features. In A. Shulman &J. C. Ballantyne (Eds.), Proceedings of the II InternationalTinnitus Seminar (pp. 195-202). Ashford, Kent, England: Invicta Press. COLES, R. A., DAVIS, A. C., & HAGGARD, M. P. (1987). Epidemiology of tinnitus in adults. In J. Hazell (Eds.), Tinnitus (pp. 46-65). London: Churchill Livingstone. COLES, R. A., SMITH, P. A., & DAVIS, A. C. (1989). The relationship between noise induced hearing loss and tinnitus and its management. In B. Bergland, U. Bergland, U. Karlsson & T. Lindwall (Eds.), Noise as a public health problem (Vol. 4) (pp. 1-12). Stockholm: Swedish Council for Building Research. DECKER, T. N., & HOWE, S. W. (1981). Auditory tract asymmetry
in brainstem electrical responses during binaural stimulation. Journal of the Acoustical Society of America, 69(4), 10841090. DECKER, T. N., & HOWE, S. W. (1982). Auditory brainstem response binaural interaction: Stimulus presentation level and auditory tract asymmetry. Journal of the Acoustical Society of America 71(4), 1033-1036. FLEMINGER, J. J., DALTON, R., & STANDAGE, K. (1977). Age as a factor in the handedness of adults. Neuropsychologia, 15, 471-473. HAZELL, J. W., WOOD, S. M., COOPER, H. R., STEPHENS, S. D., CORCORAN, A. L., COLES, R. A., BASKILL, J. L., & SHELDRAKE,
J. B. (1985). A clinical study of tinnitus maskers. BritishJournal of Audiology, 19, 65-146. HELLMAN, R. P., & MEISELMAN, C. H. (1988). Prediction of individual loudness exponents from cross-modality matching. Journal of Speech and Hearing Research, 31, 605-615. JAKES, S. C., HALLAM, R. S., CHAMBERS, C., & HINCHCLIFFE, R.
(1985). A factor analytical study of tinnitus complaint behaviour. Audiology, 24, 195-206. LINDBERG, P., LYTTKENS, L., MELIN, L., & SCOTT, B. (1984). Tinnitus-incidence and handicap. Scandinavian Audiology, 13, 287-291. LOBAUGH, P., PARKER, D., THORNTON, A. R. D., &BERLIN, C. I.
(1980). Binaural interaction asymmetries in human ABR's. Journal of the Acoustical Society of America, 68(Suppl. 1), S20. McFADDEN, D. (1982). Tinnitus facts, theories and treatments (pp. 55-116). Washington, DC: National Academy Press. NATIONAL CENTER FOR HEALTH STATISTICS (1967). Hearing levels of adults by race, region and area of residence, United States, 1960-1962 (Vital and Health Statistics Publication, Series 11, No. 26). Washington, DC: U.S. Government Printing Office. NATIONAL CENTER FOR HEALTH STATISTICS (1980). Basic data on hearing levels of adults 25-74 years, United States 19711975 (Vital and Health Statistics Publication, Series 11, No. 215). Washington, DC: U.S. Government Printing Office. PENNER, M. J. (1983). Variability in matches to subjective tinnitus. Journal of Speech and Hearing Research, 26, 263-267. PENNER, M. J. (1986a). Tinnitus as a source of internal noise. Journal of Speech and Hearing Research, 29, 400-406. PENNER, M. J. (1986b). Magnitude estimation and the "paradoxical" loudness of tinnitus. Journal of Speech and Hearing Research, 29, 407-412. SLATER, R., JONES, D., & TERRY, M. (1983). Tinnitus survey initial results from the tinnitus research group, Cardiff. British Tinnitus Association Newsletter, 20. London: Royal National Institute for the Deaf. SLATER, R., & TERRY, M. (1987). Tinnitus: A guidefor sufferers
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and professionals. London: Croom Helm. STEVENS, S. S. (1959). On the validity of loudness scale. Journal of the Acoustical Society of America, 31, 995-1003. TYLER, R. S., & BAKER, L. J. (1983). Difficulties experienced by tinnitus sufferers. Journal of Speech and Hearing Disorders, 48, 150-154. TYLER, R. S., & CONRAD-ARMES, D. (1983). The determination of tinnitus loudness considering the effects of recruitment. Journal of Speech and Hearing Research, 26, 59-72.
Received January 26, 1989 Accepted October 3, 1989
Requests for reprints should be sent to James L. Stouffer, Ph.D., Department of Communicative Disorders, Elborn College, University of Western Ontario, London, Ontario N6G 1Hl Canada.
APPENDIX UNIVERSITY OF IOWA TINNITUS QUESTIONNAIRE
Part A (To be filled in by the patient) 1. Where is your tinnitus? (Please choose only ONE answer.) f. In the head, but no exact place a. Left ear g. More in the right side of head b. Right ear h. More in the left side of head c. Both ears, equally i. Outside of head d. Both ears, but worse in left ear j. Middle head e. Both ears, but worse in right ear If you hear more than one sound or a different sound in each ear, answer the following questions with regard to the one most annoying sound. 2. Describe the most prominent PITCH of your tinnitus by circling ONE of the numbers below. Number 1 is like a VERY LOW pitched fog horn, and Number 10 is like a VERY HIGH pitched whistle. 1 2 (VERY LOW
9 10 (VERY HIGH)
3. When the tinnitus is there does it ever change PITCH? a. No b. Yes, suddenly c. Yes, gradually 4. Does the PITCH of the tinnitus vary from day to day? a. No b. Yes 5. Describe the LOUDNESS of your tinnitus by circling ONE of the numbers below. Number 1 is a VERY FAINT tinnitus, and Number 10 is a VERY LOUD tinnitus. 1 2 (VERY FAINT
LOUDNESS 5 6
9 10 (VERY LOUD)
6. When it is there, does the tinnitus ever change in LOUDNESS? a. No b. Yes, suddenly c. Yes, gradually 7. Does the LOUDNESS of the tinnitus vary from day to day? a. No b. Yes 8. Which of all these qualities BEST describes your tinnitus? (Please circle only ONE.) j. Pounding a. Buzzing k. Pulsing b. Clanging 1. Ringing c. Clicking m. Roaring d. Crackling n. Rushing e. Cricket-like o. Steam whistle f. Hissing p. Throbbing g. Humming q. Whistling h. Musical note r. Whooshing i. Popping s. OTHER. PLEASE SPECIFY
STOUFFER & TYLER: Characterizationof Tinnitus 9. Does the tinnitus ever change to a completely different sound? a. No b. Yes, suddenly c. Yes, gradually 10. During the time you are awake, what percentage of the time is your tinnitus present? For example, 100% would indicate that your tinnitus was there all the time, and 25% would indicate that your tinnitus was there V4 of the time. _______
% Please write in a single number between 1 and 100.
11. On the average, how many days per month are you bothered by your tinnitus? days per month (maximum = 30 days) Since your tinnitus began, is your tinnitus NOW: 12. a. higher
c. same IN PITCH
(circle a, b, or c)
13. a. louder
c. same IN LOUDNESS
(circle a, b, or c)
14. a. higher
(circle a, b, or c)
15. When your tinnitus first began, how many sounds was it composed of? (number of sounds) 16. How many sounds is your tinnitus composed of NOW? (number of sounds) 17. How many years have you had tinnitus? years 18. How many years has your tinnitus really bothered you? years 19. When you have your tinnitus, which of the following makes it WORSE? (CIRCLE ALL OF THESE THAT APPLY TO YOU.) a. Alcohol b. Being in a noisy place c. Being in a quiet place d. Changing head position e. Coffee/tea f. Constipation g. During your menstrual period h. Drugs/medicine i. Emotional or mental stress j. Food (please specify) k. Having just recently been in a noisy place 1. Having just recently worn a hearing aid m. Lack of sleep n. Relaxation o. Shooting guns, rifles, etc. p. Smoking q. Sudden physical activity r. When you are excited s. When you are tired from doing physical work t. While you are wearing a hearing aid u. When you first wake up in the morning v. OTHER, PLEASE SPECIFY w. Nothing makes it worse. 20. Which of the following REDUCES your tinnitus? (CIRCLE ALL OF THE ANSWERS THAT APPLY TO YOU.) a. Alcohol b. Being in a noisy place c. Being in a quiet place d. Coffee/tea e. Drugs/medicine f. Food (please specify) g. Having just recently been in a noisy place h. Having just recently been in a quiet place i. Listening to television or radio j. Sleep k. Smoking
452 Journal of Speech and Hearing Disorders
1. Wearing a hearing aid m. OTHER, PLEASE SPECIFY n. Nothing reduces my tinnitus. 21. What do you think originally caused your tinnitus? Select ONE only. a. Accident (please specify) b. Alcohol c. Drugs/medicine d. Food (please specify) e. Hearing loss f. Illness (please specify) g. Noise h. Smoking i. Surgery j. OTHER, PLEASE SPECIFY i. I have no idea. 22. Please write a single number between 0 and 100 to indicate now ANNOYING you find your tinnitus-a "0" would indicate that it is not annoying at all, a "100" would indicate that it is extremely annoying. _______ (Please write a single number between 0 and 100.) 23. What percentage of the time does your tinnitus interfere with your getting to sleep (0% = does not interfere; 100% = interferes every night). _______ (Please write a single number between 0 and 100.) 24. To what degree are you DEPRESSED by your tinnitus? (0 indicates your tinnitus does not depress you; 100 indicates you are extremely depressed by your tinnitus.) _______ (Please write a single number between 0 and 100.) 25. Do you have trouble CONCENTRATING because of your tinnitus? (0 indicates your tinnitus does not affect concentration; 100 indicates that your tinnitus always interferes with concentration.) _______ (Please write a single number between 0 and 100.) 26. Does your tinnitus interfere with your understanding speech? (0 indicates your tinnitus does not interfere with speech; 100 indicates your tinnitus interferes extremely with understanding speech.) (Please write a single number between 0 and 100.) 27. I am concerned that my tinnitus is a symptom of a much worse disease. Yes / No 28. I am concerned that I might go deaf because of my tinnitus. Yes / No 29. Were you taking any medications just BEFORE your tinnitus began? a. No
b. Yes 30. Are you taking any medications NOW? a. No b. Yes
Part B (To be filled in by the audiologist) 1. Primary Diagnosis (circle only ONE) 1. Noise-induced hearing loss 2. Presbycusis 3. Meniere's 4. Middle-ear disorder (please specify) 5. Retrocochlear (please specify) 6. Normal hearing (please specify) 7. Other (please specify) 8. Unknown 2. Primary Complaint (circle one ONE) 1. Hearing loss 2. Dizziness 3. Tinnitus
STOUFFER & TYLER: Characterizationof Tinnitus 4. Pain or headaches 5. Other (please specify) 3. Hearing Thresholds Right Ear 4000 Hz 1000 Hz
Left Ear 4000 Hz
1000 Hz 1.